Provider Demographics
NPI:1841738945
Name:OLANIYAN, BOLA (RN)
Entity Type:Individual
Prefix:
First Name:BOLA
Middle Name:
Last Name:OLANIYAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2486 N GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-1855
Mailing Address - Country:US
Mailing Address - Phone:269-925-6768
Mailing Address - Fax:
Practice Address - Street 1:2486 N GLENDALE RD
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-1855
Practice Address - Country:US
Practice Address - Phone:269-925-6768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704229754163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI52-1590951Medicaid